Fillable Vital Statistics Form printable pdf download

Vital Statistics Form

Please complete the information below as it pertains to the person for whom arrangements are being made.

This information is necessary to file the appropriate forms for Prearrangement contracts, Death Certificate and

any permits required at the time of need.

Full Legal Name:

(Including Maiden)

______________________________________________________________

Address:

_____________________________________________________________________________________

County of Residence:

__________________________________________________________________________

Residence Inside City Limits?:

Yes_____ No_____

Date of Birth:

_________________________________________________________________________________

Place of Birth:

________________________________________________________________________________

Father’s Name:

_______________________________________________________________________________

Mother’s Name:

(Including Maiden)

______________________________________________________________

Marital Status:

(Married, Divorced, Never Married or Widowed)

________________________________________

Name of Spouse:

(Including Maiden)

_____________________________________________________________

Usual Occupation:

____________________________________________________________________________

(The Bureau of Vital Statistics will not accept “retired”, we must have the occupation at the time of employment or “homemaker”.)

Industry:

_____________________________________________________________________________________

Highest level of Education Obtained:

____________________________________________________________

(i.e.: 9–12 grade, high school diploma or GED, some college, or highest level of college degree obtained.)

Social Security Number:

_______________________________________________________________________

Name and Address of Physician:

_________________________________________________________________

Veteran:

Yes_____ No_____

Branch of Service:

_____________________________________________________________________________

Informant’s Full Name:

_________________________________________________________________________

Relationship to Deceased:

______________________________________________________________________

Phone Number(s):

_____________________________________________________________________________

Email:

_______________________________________________________________________________________

Address:

_____________________________________________________________________________________

After completing the Vital Statistics Form, please send to us at your earliest convenience. Please contact us with

Houston p

Dallas p

any questions or concerns.

713-933-0356 |

713-666-0431 |

972-424-1144 |

972-424-1148

Vital Statistics Form

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